SUMMARY:

• Over 7 years of experience on projects related to Health Information Exchange (HIE), Interoperability, Medicare, Medicaid, EDI transactions (inbound and outbound: 837, 820, 834 etc.) HL7, Eligibility and Benefit systems, HCPCS, CPT, HIPAA 4010 and 5010, Claims Adjudication and expert in Affordable Care Act (ACA), aka Healthcare Reform (HCR)
• Having extensive domain knowledge in MMIS, EPIC, EDI X12, HL7, HIPAA, System, Medicare and Medicaid, CMS Compliances/Regulations.
• Expertise prioritizing, multitasking and managing multiple projects related to Medicare (Parts A, B, C, D) & Medicaid, NCPDP Version D.0, FACETS, EDI, HL - 7, CPT.
• Strong understanding of Relational databases, Data Warehousing, ETL, fact and dimensional model and Business Intelligence - Reporting with experience in the life sciences and healthcare domain.
• Involved in Processing EDPS, RAPS, and Reconciliation Reports (Recon Reports)
• Strong institutional knowledge of Medicaid; including Medicaid Information Technology Architecture (MITA), and Medicaid Management Information Systems (MMIS)
• Development of 820, 834, 837 Claim billing, 276 Status, 834 Enrollment, 835 Claim Payments, 829, 270-278 and many other healthcare maps.
• Understanding of EDI business practice and the ability to understand the client's needs.
• Strong Experience in Claims Processing and Claims Scrubbing in HMO, PPO, Medicaid and Medicare.
• Experience in Healthcare Application Facets in different modules like Claims, Membership, Provider and Billing.
• Extensive knowledge of EDPS errors which includes 254, 19, 255, 465etc., also include RAPS Errors 450, 451, 455, 400, 500 etc.
• Working experience in Health Insurance Exchange (HIX), Health Information Exchange (HIE) and Encounter Data Processing System (EDPS/RAPS).
• Experienced with Federal contracts, X12 transactions, health care act, EDI transactions 270, 271, 834, 835, 837.
• Wrote BRD, TSD, Mapping doc., test scenarios, test cases for testing the functional and non-functional aspects of both ETL and Reporting jobs.
• Worked on different EDI healthcare transactions like 834-Benefit Enrollment and Maintenance and 820-Payment Order/Remittance Advice.
• Extensive experience in all platforms of invos/open text EDI mapping software including trusted link, Biz Manager and Biz Mapper.
• Also 5010 Upgrade mapping for new B2B and existing B2B clients.
• Involved in Facet Implementation and conversion of 4.21 and also in TriZetto Facets and TriZetto HIPAA Gateway 4.11.
• Conducted internal audits and prepares audits reports to ensure compliance with Medicare, Medicaid and other institutions.
• Background of documenting HL7 and X12 interface specifications.
• Knowledgeable for gap analysis in changing old MMIS and Involved in testing new MMIS.
• Working knowledge of healthcare Technology standards such as HL7, ANSI ASC X12, IHE XDS/XDM, HITSP, CCR (continuity of Care Record), CCD (Continuity of Care Document), NCPDP Script 8.1, ELINCS, and CDA, HHS, CMS, RHIO's, IHDN's.
• Expertise in Membership Enrollment, Claims, Subscriber/Member, Plan/Product, Claims, Provider, Commissions and Billing Modules of Facets.
• Proficient in conducting Business process modeling (BPM), feasibility studies, Impact Analysis, Cost/Benefit analysis, Gap Analysis and Risk analysis.
• SQL application management, (added users, created backup and recovery plans, ran SQL scripts)
• Exceptional knowledge in testing phases with state HIX projects.
• Experience in implementation of HIPAA 4010 and HIPAA 5010 changes in the existing claim processing integrated system.
• Involved in Facets Output generation, Interface development and Facets Migration Projects.
• Experience as developing, building and maintaining data warehouse.
• Strong understanding of project life cycle and SDLC methodologies including RUP, RAD, Waterfall, Scrum and Agile.
• Operated Visual basic on different operating systems such as Windows and UNIX.
• Great attention to detail while understanding big-picture objectives and strategy
• Understanding of developing reports, dashboards, and processes to continuously monitor data quality and integrity on Salesforce.
• Strong understanding of management techniques intended to improve business processes like Six Sigma.
• Good knowledge on the different systems like policy admin, cash, print, and claims. Ability to resolve complex issue in a short time within the SLA.
• Highly motivated and initiative to learn new tools, and research new concepts, ideas, and technologies quickly.
• Strong systems/process orientation with demonstrated analytical thinking, organization skills, and problem-solving skills, willingness to train and teach others. Good interpersonal skills and ability to interact with clients.

PROFESSIONAL EXPERIENCE:

Confidential - Boston, MA

EDI Business Analyst

Responsibilities:

• Gathered detailed business and technical requirements and participated in the definitions of business rules and data standards.
• Worked on EDI transactions: 270, 271, 834, 835, and 837 (P.I.D) to identify key data set elements for designated record set. Interacted with Claims, Payments and Enrolment hence analysing and documenting related business processes.
• Performed gap analysis of claims and enrolment business process for changes from SSN identifier to USI (Unique Subscriber Identifier) affecting for HIPAA EDI X12 transactions 837, 834, U277, 276/277, 270/271, 278,835 and 820.
• Created specifications for EDI HL7 (A28, A31, ADT) and X12 (837/835) transactions that were transmitted between Claims Editor and Legacy Billing application and external Payers.
• Worked with data migration and file mapping for various EDI transactions. Enhanced the Provider/Patient verification criteria using additional parameters based on the information retrieved from the EDI 837 I/P transaction files.
• Translated the EDI X12 data into XML format for initial transformation/migration.
• Facilitated functional requirement gathering from system users and prepared business requirement documents (BRD).
• Created Business Process Mapping Diagrams and Documentation for the process improvement recommendations.
• Used MS-Visio for flow-charting, Use- Case process model and architectural design of the application.
• Implemented the Rational Unified Process (RUP) methodology guidelines with its various workflows and artifacts in Requirements Management and Development.
• Gathered and documented functional requirements and use cases for automation of operational and administrative business processes.
• Provided overall project management to multiple projects successfully completing them on-schedule and on-budget.
• Documented the "AS-IS" Business Workflows adhering to UML standards. Conducted JAD sessions to define requirements and finalize the Functional Requirement Document (FRD).
• Designed and developed Use Cases, Activity Diagrams, Sequence Diagrams, OOD (Object oriented Design) using UML and Visio.
• Interfaced with team leaders, identify and analyse the given information, procedures and decision flows, evaluated existing procedures, methods and technical documentation. Communicated with executives, managers and other stakeholders regarding project scope.
• Responsible for business process analysis that includes requirements facilitation, definition & analysis, alternatives, software selection, prototyping, business process design and mapping.
• Maintained a Traceability Matrix to ensure that all functional requirements are addressed at the use case level as well as the test case level.
• Involved in identifying use cases, actors and writing use case narratives. Created use case diagrams and activity diagrams using MS Visio.
• Conducted meetings and JAD sessions for project definition, resource identifications and deliverable prototype identification.
• Interfaced with developers, analysts, customers and project managers to discuss requirements and recommended solutions, to help resolve issues.
• Led the User Acceptance Testing efforts to verify that the developed reports meet the requirements.
• Involved in developing the test strategy and helped in developing QA Test plans for Functional, Integration and System Testing.

Environment: Quality Center, Excel, Outlook, MS Office, MS Project, project management, Rational Rose, Rational Requisite Pro, RUP, UML.

Confidential - Franklin, TN

Business Analyst/ EDI Analyst

Responsibilities:

• Associated with full HIPAA Compliance life-cycle from gap analysis, mapping, implementation and testing for processing of Medicare, Medicaid and Tri-care claims.
• Involved in the initial discovery/analysis phase for projects to determine the scope and impacts to the data warehousing systems.
• Configuration of Trizetto systems using advanced MS Word
• Worked with the team on FACETS claims processing system and gathered requirements to comply with HIPAA.
• Produced BRDs and FRDs for RAPS and EDPS process to automate return file management process and achieved accomplished efficiency in saving processing time by 95%.
• Set claim processing data for different Facets Module.
• Involved in integration of FACETS with legacy and third-party vendor applications.
• Establish documentation for Agile methodology for implementation with a very water-fall-centric development team.
• In depth Understanding of HIPAA X12 EDI transaction 834 for enrollment and eligibility, X12 EDI transaction 820 for Payment Order/Remittance Advice, Acknowledgement transactions 999 and TA1.
• Performed analysis of enrollment and eligibility data in the XML format to determine if data is compatible with X12 data.
• Created 834 X12 format using Edifecs Specbuilder and Note Pad ++.
• Developed Schemas of EDI x12 Claims (837) and Eligibility forms in XML.
• Responsible for the core activities of the test team including creating and executing test cases, analyzing and documenting results and drawing a traceability matrix to match the requirements with the final test scenarios.
• Worked on report creation skills using Microsoft SQL Reporting Services (SSRS)
• Participated in release cycles of software developed using Waterfall and Agile methodologies.
• Integrated various systems with HEDIS and create design for HEDIS and other systems to pull data in HEDIS.
• Assists with TRR and MRR reconciliation, along with the investigation, correction, and tracking of enrollment transaction
• Knowledge of health care services regulatory environment in compliance with HIPAA, MITA, MMIS and EDI
• Proficient in writing SQL queries for testing and data validation.
• Develop, test, modify and manage EDI (x12 standard) maps using B2B mapping tool in the Healthcare industry.
• Responsible for preparing Software Requirement Specification (SRS) and documenting them.
• Employed UML methodology in creating UML Diagrams such as Use Cases, SequenceDiagrams, and State Diagrams, Activity Diagrams and business process and workflows.
• Strong experience working in Software Development Life Cycle (SDLC) using various methodologies including Agile, Waterfall.
• Involved in project planning, coordination and QA methodology in the implementation of the Facets in the EDI transaction of the claims module.
• Evaluated and performed testing within Facets for Rejected QA Scenarios.
• Worked on Member Management, Eligibility, Claims and Billing modules within FACETS.

Confidential - Houston, TX

Business Analyst/EDI Analyst

Responsibilities:

• Analyzed existing business units, business/Application and their Interfaces with their capability through open-ended discussions, brainstorming sessions, and prototyping, prioritizing them and converting them as business requirements that must be included while developing the software.
• Created Data Flow Diagrams (DFD's), ER diagrams for data modeling and web-page mock-ups using MS - Visio for acceptance from end users.
• Experience in Data Warehousing; responsible for data mapping activities including maintaining mapping
• Analyzed data and created reports using SQL queries for all issued Action Items.
• Experience working with ETL specifications and ANSI X-12 data translations
• Define business requirements and business process and policy changes related to the client Medicaid system during the conversion from the existing HIPAA 4010A formats to the future HIPAA 5010A format
• Analyze and document Medicaid EDI transactions issues related to implementation of HIPAA 5010 and ensure these issues are documented and addressed in the approach to the HIPAA 5010 version.
• Converted the XML files into X12 and X12 to XML files on GIS for sending and receiving the EDIfiles.
• Also worked on multiple 837s and multiple Eligibility (270/271) and healthcare claim status (276/277)
• Responsible for the development and implementation of HIPAA EDI Map sets 270, 271, 276, 277, 820, 834, 835, 837 and 5010.
• Reviewed the application systems and determined how to map the new applications data to the EDI System.
• Create EDI interface to send purchase order requests and receive acknowledgments and invoice data.
• Mainly assisted with documenting processes, used agile methodology to write the System Requirements documents and designed Functional specifications.
• Conducted UAT. Wrote SQL queries in MS Access and Oracle for data manipulations.
• Used Agile and Rational methodology in the project development for Rational Test Suite for various phases of RUP.
• Proficient with QNXT claims processing platform.
• Developed Use Cases, Use Case Diagrams, UML Diagrams, Activity Diagrams, Sequence Diagrams, Class Diagrams in Rational Rose
• Utilized RUP to configure and develop process, standards, and procedures.

Confidential - Tampa, FL

Business Analyst

Responsibilities:

• Gathered requirements and prepared business requirement documents (BRD)
• Responsible for translating BRD into functional specifications and test plans.
• Closely coordinated with both business users and developers for arriving at a mutually acceptable solution.
• Conducted JAD sessions to define the project and to reduce the time frame required to complete deliverables.
• Created and maintained data mapping document (s) in reference to the claim process transactions.
• Involved in processing the claims to ensure claims are being processed correctly
• Used Rational Rose/MS Office Suite for creating use cases, workflows and sequence diagrams according to define the Data Process Models.
• Involved in /EDI transactions Analysis, Design, Implementation and Documentation.
• Reviewed in preparing the Test Scenarios for Health Care Claim Payment/Advice.
• Maintained Requirement Traceability Matrix (RTM)
• Presented the nursing outcomes to C-Level executives in Gentiva Nursing and Data Management group using Crystal Reports XI.
• Use Case development using modeling tool MS Visio.